Ambulatory Care Systems
Abueva, Michelle Louise P.
On April 27, 2004, President George Bush announced a goal to establish electronic health records (EHRs) for all citizens within a 10-year time frame. He created the position of a national health information technology coordinator to develop a nationwide interoperable health information technology infrastructure. One responsibility is to improve “the coordination of care and information among hospitals, laboratories, physician offices, and other ambulatory care providers through an effective infrastructure for the secure and authorized exchange of health care information” (White House Executive Order, 2004).
In July, Health and Human Services Secretary Tommy G. Thompson announced the “Decade of Healthcare Information Technology” and announced the publication of a report which reveals how vital it is to have automation in the physician’s and ambulatory offices.
The report identifies four major goals, with strategic action areas for each (Decade, 2004):
Goal 1: Information Clinical Practice. Bringing information tools to the point of care, especially by investing in HER systems in physician offices and hospitals.
Goal 2: Interconnect clinicians. Building an interoperable health information infrastructure, so that records follow the patient and clinicians have access to critical health care information when treatment decisions are being made.
Goal 3: Personalize Care. Using health information technology to give consumers more access and involvement in health decisions.
Goal 4: Improve population health. Expanding capacity for public health monitoring, quality-of-care measurement and bringing research advances more quickly into medical practice.
Where Ambulatory Clients are Being Treated
As a response to increasing costs of providing healthcare, the health care industry has moved away from expensive inpatient, acute care environment to caring for clients in various ambulatory care setting.
Ambulatory healthcare organizations
Single specialty providers
Other organizations that serve ambulatory population
health maintenance organizations
single- and multispecialty group practices
independent physician associations
college and university health services
cardiac catheterization centers
oral and maxillofacial surgery centers
pain management centers
infusion therapy services
plastic surgery centers
radiation/ oncology clinics
urgent/ emergency care centers
women’s health centers
prison health centers
community health centers
nurse managed centers
Indian health centers
faculty medical practices
hospital-sponsored ambulatory health services
pain management clinics
urgent and immediate health centers
groups of ambulatory care organizations
office-based surgery centers and practices
Issues for Ambulatory Care
Issues include the following: increased accountability, the need for continuous and documented service improvements, pressures to control utilization, and the protection of confidential information.
Effective reimbursement of services. It is the paramount for continued operation.
Applications Necessary in the Ambulatory Environment
Ambulatory care information systems, usually computer-assisted, are designed to store, manipulate, and retrieve information for planning, organizing, directing, and controlling administrative and clinical activities associated with the provision and use of ambulatory care services and facilities.
Major application areas
patient and staff scheduling
managed care functionality
Financial benefits of the implementation of an automated information system include a cost-effective and timely bill submission process resulting in decreased days in accounts receivable and the reduction of rejected claims. Client benefits need to be verified and accurate insurance information obtained.
Electronic data interchange. Large ambulatory care organizations use electronic data interchange (EDI) to automate the exchange of data such as claims, submittals and remittances, and health plan eligibility information.
Credit cards. Some organizations also provide integrated credit card payment applications. If the client does not pay the bill within a predefined time period, a collections process must be instituted.
Adjudication. The electronic or manual system must support adjudication which is the process of determining which payer pays which portion of the bill.
Eligibility process. The eligibility process needs to be conducted with each instance of service as clients may have changed insurance plans.
Claims. Claims may be either electronic or paper. In the ideal electronic system, claims are edited prior to submission so that charges are paid and not rejected which necessitates further processing, costing time, and money.
Administrative benefits of implementing an automated information system
Additional benefits for automated ambulatory care records
reduction in the size of the record room
reduced time spent finding and delivering charts
increase in the privacy of data
formats that are legible and comply with legal regulations
promotion of quality assurance
improved patient satisfaction
ability for home access by physicians and nurse practitioners
alerts for incomplete data
integration of clinical data
Scheduling system. The patient scheduling system must link existing scheduling systems so that scheduled activities are coordinated across locations to schedule appointment times, providers, resources, and locations throughout the hospital and organization.
Credentialing. Credentialing is the exhaustive verification of the medical licenses and qualifications. Healthcare providers must be recredentialed on a regular basis in order to provide services. An automated system can enhance maintenance of this data.
Applications for the clinical area can encompass a clinical decision support system, e-Prescribing, and evidence-based medicine.
The automated healthcare record can provide the following:
automated ambulatory care provider order entry (ACPOE)
a medication record
laboratory and radiology department results
alerts and reminders
a follow-up system
Master patient index. It is the basis for collection of all patient-related data. It is central repository for patient/ member information across the enterprise including sophisticated tools for querying, updating and managing the index.
Registrations system. It collects patient demographics and insurance information.
Referrals. These are required by many health plans when a patient is to be seen to another healthcare provider. Automatic transfer of these requests will aid patient care and payment of the bill.
Contracts. The multitude of contracts between the healthcare facility and the payer need to be documented and managed through a contract administration function.
Reports. Reports must be included in any information technology application. Beyond standard reports, the user must be able to generate user-specified reports.
Medical record location. It can be tracked automatically with an automated system.
Systems must support the resource based relative value scale (RBRVS) and the relative value unit (RVU).
RBRVS procedure fee pricing is a model designed by the Department of Health and Human Services (DHHS). In this system, each physician’s current procedural terminology (CPT) code has a relative value associated with it. The payer will pay on a monetary multiplier for RVS value.
The Health Care Portability and Accountability Act of 1996 requires six code sets.
Current Procedural Terminology, 4th Edition (CPT)
Ninth Revision of the International Classification of Diseases (ICD-9-CM)
Healthcare Common Procedure Coding System (HCPCS)
National Drug Code (NDC)
Code on Dental Procedures and Nomenclature
CPT codes describe medical procedures performed by physicians and other healthcare providers. It was developed by the American Medical Association (AMA) to assist in the assignment of reimbursement amounts to providers by Medicare carriers. The most recent version is CPT 2004, which contains 7,755 codes and descriptors (AMA, 2004).
The ICD-9-CM (CMS, 2004) is based on the official version of the WHO’s ICD-9 (2004). It is designed for the classification of morbidity and mortality information for statistical purposes, for the indexing of hospital records by disease and operations, and for data storage and retrieval. Diagnoses and procedures coded in it determine the Diagnosis-related group (DRG) that controls reimbursement by CMS programs.
The HCFA HPCS (2004) is a collection of codes that represent procedures, supplies, products, and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs.
The NDC system identifies pharmaceuticals in detail including the packaging. Its use is required by the FDA for reporting and it is used in many healthcare information systems to aid in reimbursement. The directory is available on the Internet at www.fda.gov/cder/ndc/index.htm.
Ambulatory Medication Classification (APC) System is a prospective payment system for hospital out-patient services. It was mandated by Congress as part of the Balanced Budget Act of 1997 (Public Law 105-32). It also makes it possible for outpatient managers to determine patterns, to predict cost of resource use, and to evaluate managed care and physician contracts.
Centers for Medicare and Medicaid Services (CMS) formerly known as the Health Care Financing Administration.
Health plan employer data and information set (HEDIS) is a standardized, comprehensive set of indicators used to measure the performance of a health plan.
Outcome and assessment information set (OASIS) regulations for the home care industry. Its purpose is to provide a comprehensive assessment for an adult home care patient and measure patient outcome for purposes of outcome-based quality improvement.
Implementation Issues and Challenges
Based on 7,808 ambulatory care facilities, in 2004 84% were not automated, 13% had software installed and 3% had a contract signed but the software was not implemented (HIMSS, 2004). Only 7% planned to purchase software.
Physicians are asking national policymakers to assist in the adoption of information technology in the clinical area by offering federal loans, grants, tax incentives and matching funds.
The Role of the Nurse Using Informatics Concepts in the Ambulatory Arena
The nurse is a user of the data contained in automated systems. The objective is to take the data and put it together in meaningful ways, making information. All nurses must be mindful on the confidentiality and security of information.
An automated system can help in this management of data and the transformation from data to information to knowledge.
Use of reports: health management of patients, managing the administrative aspects of the practice, generating financial information, or for conducting research.
Member Associations Involved in Ambulatory Care
Major Ambulatory Care Organizations:
The American Academy of Ambulatory Care Nursing, AAACN (http://www.aaacn.org/) is a member organization specifically for nurses. It offers networking opportunities for the membership by geographic location through local networking groups and by specialty practice through special interest groups (SIGs). They offer publication through publications, electronic media, and conferences. Headquarters: East Holly Avenue, Box 56 Pitman, NJ
The American Medical Informatics Association, AMIA (http://amia.org) has physicians and nurses amongst their membership. Contact Information: AMIA, 4915 St. Elmo Avenue, Suite 401, Bethesda, MD 20814
The Medical Group Management Association, MGMA (http://www.mgma.com/), founded in 1926 and based in Colorado, is a major organization in the US representing physicians in group practice nationwide. This supports education, networking, job recruitment, research and political action. Headquarters: 104 Inverness Terrace East, Englewood, CO
The Society for Ambulatory Care Professionals (http://www.aha.org) is associated with American Hospital Association. It is an organization of management professionals across the continuum of healthcare services, including outpatient, ambulatory, and home healthcare in hospital and freestanding settings. They offer networking opportunities, education, publications, and legislative advocacy.
The Federated Ambulatory Surgery Association, FASA (http://www.fasa.org/) is a nonprofit association representing the interests of ambulatory surgery centers in the US. This represents the physicians, nurses, administrative staff, and owners industry before the media, Congress, state legislatures, and regulatory bodies. Location: Fairfax St., Alexandria, VA
The American Association of Ambulatory Surgery Centers, AAASC (http://www.aaasc.org/) is a member organization that promotes advocacy at the national level through relationships with the CMS and Congress, networking and educational opportunities. Location: Johnson City, TN
The Association for Ambulatory Behavioral Healthcare (http://www.aabh.org/) is an international organization of ambulatory mental healthcare providers dedicated to the delivery of high-quality psychiatric and chemical dependency treatment within a continuum of care. This started about 1975 is based in Fairfax, Virginia. Location: Waples Mill Rd., Fairfax VA
American Health Information Management Association (http://ahima.org/) with over 46,000 members is an organization of health information management professionals. The purpose is to foster the professional development of its members through education, certification, and lifelong learning thereby promoting quality information to benefit the public, the healthcare consumer providers, and other users of clinical data. Location: Michigan Avenue, Chicago, IL
The Healthcare Information Management Systems Society, HIMSS (http://www.himss.org/) has formed an Ambulatory care Committee. The HIMSS Ambulatory Care Initiative was created in response to trends such as the aging population, the increasing prevalence of chronic diseases, and the development of minimally-invasive procedures that can be performed without hospitalization. Location: East Ohio St., Chicago, IL
Ambulatory Information Management (AIM) association, a local group and a specialty organization of the California Health Information Association (CHIA).
Accrediting organizations validate standards of practice and promote quality care.
Accreditation Association for Ambulatory Health Care, AAAHC (http://www.aaahc.org/accreditation/coop_agree_faq.shtml) is a private, not-for-profit organization formed in 1979 aims to develop standards and conduct a survey and accreditation program.
COLA, headquartered in Columbia, Maryland, is a non-profit, physician-directed, and national accrediting organization. Its purpose is to promote excellence in medicine and patient care through programs of voluntary education, achievement, and accreditation (http://www.cola.org).
The National Committee for Quality Assurance, NCQA (http://www.ncqa.org) is a private, non-profit organization dedicated to assessing and reporting on the quality of managed care plans governed by a board of directors.
Journals and Conferences
Healthcare professionals who work in the ambulatory care arena need to keep up with regulatory and practice changes in the environment. Among the ways to obtain an education include journals and conferences, as well as membership in organizations.
The Journal of Ambulatory Care Management is a quarterly publication. Each issue focuses on one topic of interest related to ambulatory care. This started in 1999, is available both on the World Wide Web and in hardcopy for a fee.
The Ambulatory Pediatrics is a publication of the Ambulatory Pediatric Association.
The Journal for Healthcare Quality is a publication started in 1979 by the National Association for Healthcare Quality.
The Medical Group Management Association (MGMA), one of the best know with the largest attendance is a conference which provides a wide range of educational programs on topics that medical group practices need to be aware of.
The American Medical Informatics Association, AMIA (www.amia.org) meets twice yearly, primarily in Washington, DC area. Over 3,000 attendees meet primarily to discuss hospital and clinic use of technology.
TEPR, sponsored by the Medical Records Institute (http://www.medrecinst.com/conferences/tepr/)
Future Directions for the Adoption of Information Technology in Ambulatory Care
Some ambulatory practices
using electronic mail
smart card technology
The goals set by President Bush and the appointment of Dr. David J. Brailer as the national coordinator will inject momentum into the adoption of automated system into ambulatory care.
Computerized provider order entry (CPOE) systems. There is a move to use this in ambulatory care. The biggest area of impact is that of medication safety where it is thought that adverse drug events could be prevented. An estimate for the use of electronic prescribing of medications is now between only 5 and 18% of physicians and other clinicians (eHealth Intiative, 2004).
Goal of EHRs. Automating the physician’s offices and ambulatory care practices is a primary step in the goal of EHRs for all citizens.
Internet Tools for Advanced Nursing Practice
Tan, Faith Rodessa Jade A.
Information relevant to clinical decision-making continues to expand, and its relevance will only increase as the electronic health record becomes a standard part of practice. Health care settings are integrating clinical information systems into all aspects of care planning, delivery, and evaluation. To prepare clinicians to recognize and capitalize on the potential of this information to affect health outcomes, internet tools need to be integrated into clinical course work. Internet applications can be used for clinical-decision support, patient and clinician e-mal communication, and point-of-care electronic health record data entry, data sharing and messaging including prescription writing.
Basic and Advanced Internet Search Methods
Basic and advanced internet search skills are needed to adapt to a frequently changing Internet environment and to retrieve the wealth of Internet information applicable to clinical practice in an efficient manner. Search methodologies, if applied correctly, increase the efficiency of retrieval of needed information. Search efficiency is maximized and cost is minimized, where cost stands for search time. Three strategies are provided to facilitate easy search:
1. Name Precisely the information being sought
If the search terms used are precisely chosen, the searcher goes directly to the desired information.
2. Use a search string
Use one or more search terms(search string) rather than a single word to increase the preciseness of a search.
3. Enhance search strings by Boolean or natural language methods.
Boolean terms: AND, OR, or NOT.
AND- used to create a search string that precisely expresses the intent of the searcher.
OR- used when equivalent terms or synonyms are used to capture the information required.
Internet- Available Clinical Practice Tools
Internet Available Clinical Practice tools is clinically useful, help clinicians organize their own knowledge, databases and facilitates ready access to needed information. This structured approach is divided into the most basic components of the nursing process: assessment , diagnosis, treatment and outcomes evaluation.
Assessment refers to the systemic collection of data needed to arrive at one or more diagnoses, The tools included in this section include forms, miscellaneous, screening tools, risk assessment instruments and information of the manifestation of signs and symptoms.
Body Mass Index Calculator-
National Heart, Lung and Blood Institute
Cancer Risk Tools-
Harvard Center for Cancer Prevention. Risks
Coronary Heart Disease Risk Calculator
National Heart, Lung, and Blood Institute
Health Risk Calculators
University of Maryland Medicine
Signs and Symptoms Manifestations
National Library of Medicine- Medline Plus Health Information http://medlineplus.gov/
Miscellaneous Screening Tools
Alcohol abuse and alcoholism
National Institute of Alcohol Abuse and Alcoholism www.niaaa.nih.gov
Multiple assessment screening tools
Insert health topic desired in search box.Wheeler Clinic Connecticut Clearinghouse, www.ctclearinghouse.org